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At this special time of the year, I offer a message of Christmas cheer to nine of our nation's Governors. This is not random pick. These are the nine who have declared they will not allow their respective states to participate in the expansion of Medicaid to all their states' uninsured residents with incomes below 133% of the federal poverty line, beginning on January 1, 2014. Merry Christmas!

Under the Affordable Care Act/Obamacare, all states were required to participate in this expansion. The U.S. Supreme Court ruling, this past June 28, made the Medicaid expansion an option for states to decide. According to the survey conveyed in the map below, 9 Governors have decided no, 5 are leaning no, 5 are leaning yes, 14 are definite yes, and 17 are still undecided. Here I want to focus on the 9 definite nos.

What is 133% of the federal poverty line? For a single adult in 2012, it means surviving on an annual income of less than $14,856; for a family of four, it means surviving on an income of less than $34,845. Not much. Not much room to afford the cost of health insurance, even if available. That's why Congress chose in the ACA to make Medicaid available to all low income Americans beginning in 2014. Of the 32 million uninsured Americans who were supposed to get health insurance via the ACA, fully 16 million were supposed to get it through Medicaid; another 16 million with incomes between 134-400% of the federal poverty line are projected to obtain private, subsidized insurance through the new state or federal health insurance exchanges beginning on 1/1/2014.

The Congressional Budget Office has estimated that, because of the Supreme Court decision making Medicaid expansion a state option, only about 10 million uninsured Americans will get covered this way, 6 million fewer. They fit into two groups: those with incomes between 100 and 133% versus those with incomes below 100% of poverty. The former group, 100-133, will be able to obtain private insurance through the new Exchanges, while the latter group, in states that choose not to expand Medicaid, will be left out in the cold. Of the 6 million, an estimated 3 million will get coverage through Exchanges, and an estimated 3 million will be out in the cold.

So here's a terrible irony. Under the ACA -- post-SCOTUS -- every American will be entitled to obtain some form of health insurance by 2014, except poor persons in states that choose not to expand Medicaid. The one officially disenfranchised group of citizens and legal residents will be poor persons who live in the wrong states.

So now, on Christmas Day, we have a Gang of Nine, nine governors saying "no" to expanding Medicaid on 1/1/2014 even though the federal government will pay 100% of the cost for 2014, 2015 and 2016, with the federal share dropping to 90% by 2019; standard Medicaid, by contrast, reimburses states an average of 56% depending on a state's per capita income. In short, the Medicaid expansion is a great deal for states. The Urban Institute estimates that over the first ten years, the federal government will pay $952B while participating states will pay $76B, so, on average, every dollar a state spends generates about $12 dollars in federal funding.

Ironically, the states represented by the nine Governors are among the states with the highest proportions of uninsured residents in the nation. In Texas, for example, one of three working adults under age 65 is uninsured. Here is a list of the nine states, along with the name of the Governor, the number of uninsured residents with incomes below 100% of the federal poverty line, and the amount of federal money over ten years the state would receive for expanding Medicaid:

Alabama: Gov. Robert Bentley; 358,000; $14.3B

Georgia: Gov. Nathan Deal; 792,000; $33.7B

Louisiana: Gov. Bobby Jindal; 345,000; $15.8B

Maine: Gov. Paul LePage; 47,000; $3.1B

Mississippi: Gov. Phil Bryant; 279,000; $14.5B

Oklahoma: Gov. Mary Fallin; 281,000; $8.6B

South Carolina: Gov. Nikki Haley; 369,000; $15.8B

South Dakota: Gov. Dennis Daugaard; 46,000; $2.1B

Texas: Gov. Rick Perry; 1,955,000; $55.6B

So what is not to like? Providing health insurance coverage to your neediest residents almost entirely on the federal dime? Well, from the nine Governors' perspective, each one's political base is fiercely hostile to Obamacare and everything in it, especially Medicaid. Even though Governors will have to pay no more than 10% of the cost, that is more than nothing. And if Republicans ever achieve their national political goal of block granting and capping Medicaid at the federal level, states will be left holding the bag.

And still:

I recall, throughout my time in Washington DC between 2008-10 working on the creation of the Affordable Care Act, constant accusations by ACA opponents that health reform would lead to "health care rationing" -- the deliberate denial of medical services to certain groups because of cost. In fact, if you scroll through the text of the ACA, you will find repeated references to prohibitions on rationing just to provide political protection against those charges.

Rationing is a word that is least popular among Republicans who use the term quite generously to criticize health care reform proposals they don't like. But what is the denial of Medicaid coverage to a state's poorest citizens other than rationing -- especially when everyone else in the state will have some form of guaranteed coverage? The deliberate denial of medical services to certain groups because of cost, that's what this is.

Research from my colleagues at the Harvard School of Public Health, including Kate Baicker and Ben Sommers, offers hard evidence that individuals covered by Medicaid have better access to medical services and have lower rates of morbidity and mortality than their uninsured counterparts. The evidence doesn't get much stronger.

So on this special day, I wonder if any of the nine will have the opportunity to reflect on the choices they are making, not affecting themselves or their families, but profoundly affecting the health and well-being of so many of their vulnerable constituents? I hope at least some of them, when it comes to expanding Medicaid, are able to ask the question: "What would Jesus do?"

Merry Christmas everyone.

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